Lopez, Maria Sofia B.

9/29/2020

3-BSN-B Prof. Zoleta

NURSING CARE PLAN

NURSING PLANNING
ASSESSMENT DIAGNOSIS GOAL / NURSING RATIONALE EVALUATION
EXPECTED INTERVENTIO
OUTCOME NS
• Ineffective After a series -Assessed vital -to assist in After a series
Subjective: breathing of nursing signs and creating an of nursing
“Ang bilis niyang pattern intervention, breathe sounds accurate intervention,
huminga at ang related to the patient diagnosis the patient able
lakas niya airway will be able to and monitor to establish a
humilik kapag obstruction establish a effectiveness normal,
natutulog” as as evidenced normal, of medical effective
verbalized by the by loud effective treatment respiratory
patient’s mother. snoring, respiratory pattern as
nasal flaring, pattern as evidenced by
Objective: tachycardia, evidenced by - Encouraged - These normal
-irritability tachypnea, normal sustained deep techniques respiratory rate
-nasal flaring use if respiratory breaths by: promote and decreased
-Tachycardia accessory rate and deep loud snoring.
-Tachypnea muscles to decreased Using inspiration,
-use if accessory breathe, RR loud snoring. demonstration: which
muscles to 28 pm. -highlighting increases
breathe slow inhalation, oxygenation
-vital signs: holding end and prevents
T: 37.4 inspiration for a atelectasis.
P: 130 cpm few seconds, Controlled
R: 28 bpm and passive breathing
exhalation methods may
-Utilizing also aid slow
incentive respirations
spirometer in patients
-Requiring the who are
patient to yawn tachypneic.
Prolonged
expiration
prevents air
trapping.

- Provided - Beta-
respiratory adrenergic
medications and agonist
oxygen, per medications
 doctor’s orders. relax airway
smooth
muscles and
cause
bronchodilati
on to open
air passages.

- Encouraged - Extra
frequent rest activity can
periods and worsen
teach patient to shortness of
pace activity. breath.
Ensure the
patient rests
between
strenuous
activities.

NURSING PLANNING
ASSESSMENT DIAGNOSIS GOAL / NURSING EVALUATION
EXPECTED INTERVENTION RATIONALE
OUTCOME S
 •Impaired gas After a -Monitored skin -Duskiness After a series
Subjective: exchange series of and mucous and central of nursing
“Sumasakit ulo related to nursing membrane color cyanosis intervention,
ko tuwing altered intervention, indicate the patient
gigising ako oxygen supply the patient advanced able to
tapos parang due to will be able hypoxemia demonstrate
medyo hinihingal obstruction o demonstrate improved
din kahit wala airways as improved -Assessed vital -to assist in ventilation and
naman akong evidenced by ventilation signs, cardiac creating an adequate
ginagawa,” as irritability, and rhythm, accurate oxygenation.
verbalized by the nasal flaring, adequate respiratory rate, diagnosis
patient. tachycardia, oxygenation depth use of and monitor
tachypnea, . accessory effectivenes
Objective: PR 130 cpm, muscles, etc. s of medical
-irritability and RR 28 treatment
-nasal flaring bpm.
-Tachycardia
-Tachypnea -Elevated head -to expand
-use if accessory of the bed, assist the lungs
muscles to patient to and to ease
breathe position work of
-vital signs: breathing
T: 37.4
P: 130 cpm -Encouraged -to promote
R: 28 bpm frequent position optimal
changes, deep chest
breathing, and expansion
coughing and
exercises. drainage of
secretions

-Provided -to supply

supplemental oxygen
oxygen at lowest
concentration as
ordered by the
physician
 NURSING PLANNING
ASSESSMENT DIAGNOSIS GOAL / NURSING RATIONALE EVALUATION
EXPECTED INTERVENTIO
OUTCOME NS
Subjective: Sleep After a series -Placed the -to promote After a series
“Hindi siya deprivation of nursing patient into wellness of of nursing
mapakali at related to interventions, comfortable the patient interventions,
parang hindi siya sleep apnea the patient room. the patient able
humihinga kapag as evidenced will be able to to report
natutulog” as by “Hindi siya report -Assessed for -to have a improvement in
verbalized by the mapakali at improvement the patient comparison in sleep and rest
patient’s mother. parang hindi in sleep and sleep pattern baseline pattern.
siya rest pattern.
Objective: humihinga -Determined -to know the
-irritability kapag medical reason of the
-vital signs: natutulog” as diagnoses that sleep
T: 37.4 verbalized by affect the deprivation
P: 130 cpm the patient’s sleep.
R: 28 bpm mother.
-Determined -helps identify
interventions appropriate
client has tried options
in the past

-Elevated head -to promote

of the bed, lung
assist patient to expansion
position